Mind Elevation - Website Intake Form

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Area Code

Phone Number

4

Preferred Contact Method:* This field is required.Choose one or more

Email

Phone

Text

5

How Can We Help?* This field is required.Please select the primary reason for seeking therapy:

Stress & Anxiety Management

Trauma & PTSD Recovery

Relationship Challenges

Grief & Loss

Personal Growth & Life Transitions

Burnout & Work-Life Balance

Child/Family Concerns

Other

6

Are you interested in:* This field is required.

In-Person Sessions

Virtual Sessions

Intensive Therapy (In-Person ONLY)

Ketamine-Assisted Psychotherapy

Play Therapy

Other

7

Additional NotesIs there anything else you would like us to know before we connect with you?